Hemodialysis

Hemodialysis is a treatment typically done in healthcare settings that filters waste and water from the blood. Blood is filtered outside the body in a dialyzer, also known as an artificial kidney. Frequent access to the bloodstream via a catheter or insertion of needles into the fistula or graft are required for this treatment (IPRO, 2017).

    Healthcare Associated Infections (HAI) in Hemodialysis Settings

    Like many receiving treatments in a healthcare setting, there is an increased risk of acquiring a Healthcare Associated Infection (HAI) with hemodialysis treatment. Bloodstream infections (BSI), Carbapenem-resistant Enterobacterales (CRE), Extended-Spectrum Beta-lactamases Enzymes (ESBL), Methicillin-resistant Staphylococcus aureus (MRSA), Multi-drug resistant Acinetobacter, Multi-drug resistant Pseudomonas, and Vancomycin-resistant Enterococci (VRE) are antibiotics resistant HAIs that are related to one in four catheter-site infections. Clostridioides difficle (C.Diff) is the most common HAI in healthcare settings but is not antibiotic resistant (IPRO, 2017). 

    Risk factors for developing HAIs include (Fisher et al., 2020 & Abbasi et al., 2020):

    • Hospitalization
    • Age (annual increase is associated with a higher chance of death or hospitalization)
    • Vascular access (specifically central venous catheters)
    • Prolonged hemodialysis treatment (longer catheterization duration)
    • Co-morbidities (diabetes)
    • Poor patient hygiene
    • Prior infections
    • Surgical procedures

    There is evidence that early referral of patients to nephrologists, an integrative team of healthcare specialists, and a vascular access coordinator (to provide patient education) play a role in decreasing risk factors related to HAIs (Fisher et al., 2020). HAIs can be prevented with proper infection control measures (Table 1).

      It is predicted that 65-70% of HAIs in dialysis settings can be prevented using proper infection control measures (IPRO, 2017). In partnership with the Centers for Disease Control and Prevention (CDC) Making Dialysis Safer for Patient Coalition, the Nevada Department of Health and Human Services Healthcare Associated Infections (HAI) program encourages dialysis facilities to utilize the CDC’s core interventions and resources to prevent the spread of HAIs. The core interventions include:

      • Surveillance and feedback using National Healthcare Safety Network (NHSN)
      • Hand hygiene observations
      • Catheter/vascular access care observations
      • Staff education and competency
      • Patient education/engagement
      • Catheter reduction
      • Chlorhexidine for skin antisepsis
      • Catheter hub disinfection
      • Antimicrobial ointment

      More information can be found at Making Dialysis Safer for Patients Coalition | Dialysis Safety | CDC.

        Infection Control/Prevention Measures

        During dialysis treatments, multi-drug resistant organisms (MDROs) can be spread by contact transmission; commonly by a patient from a healthcare worker (hands), then to another patient (CDC, 2021). Environmental surfaces, like countertops, patient beds, and medical equipment, may become contaminated and serve as a reservoir for pathogens.

        Transmission can occur when a healthcare worker touches a contaminated environmental surface then touches the patient (CDC, 2021). To prevent the spread of MDROs, healthcare facilities are expected to practice infection control measures. The Centers for Medicare & Medicaid Services (CMS) requires hemodialysis to comply with the CDC Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients (cdc.gov). Many of these infection control practices are standard precautions and should not present any additional burden on facilities. Standard precautions are the minimum infection control practices that should be applied to all patients, regardless of their MDRO status (CDC, 2021). In addition to standard precautions, more rigorous practices for hemodialysis facilities need to be taken into consideration.

        Preventing transmission of MDROs among hemodialysis patients requires hemodialysis facilities to implement a thorough infection control program. Policies and procedures specific to hemodialysis facilities should include, routine testing, specific immunizations (Table 2), surveillance reporting, healthcare training and education, and patient training and education.

          Dialysis Reporting Requirements

          The National Healthcare Safety Network (NHSN) requires dialysis facilities to complete:

          • Survey Annually 
          • Monthly Reporting Plans
          • Report Denominator Data Monthly
          • Report Numerator Data Monthly

          The Dialysis Event Surveillance Protocol reviews the required dialysis facility reporting. Dialysis facilities are required to report the following events, IV antimicrobial start; positive blood cultures; and pus, redness, and an increased amount of swelling at the vascular access site (Table 3).

            In addition, facilities reporting to NHSN and participating in the Centers for Medicare and Medicaid (CMS) End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) must follow the Dialysis Event Surveillance Protocol. Section 153(c) of The Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 directs the Secretary of the Department of Health and Human Services (HHS) to establish incentives for facilities providing renal dialysis services. ESRD QIP requirements can be found in Section 1881(h) of the Social Security Act (SSA). More information on CMS ESRD reporting requirements can be found on ESRD Quality Incentive Program.

              References

              Abbasi, S., Aftab, R., and Chua, S. (2020). Risks Factors Associated with Nosocomial Infections among End Stage Renal Disease Patients Undergoing Hemodialysis: A Systematic Review. National Institutes of health. Doi: 10.1371/journal.pone.0234376

              Centers for Disease Control and Prevention (CDC) (2021). Infections Prevention in Dialysis Settings. U.S. Department of Health & Human Services. https://www.cdc.gov/dialysis/clinician/ce/infection-prevent-outpatient-hemo.html

              Fisher, M., Golestaneh, L., Allon, M., Abreo, K., and Mokrzycki, M. (2020). Prevention of Bloodstream Infections in Patients Undergoing Hemodialysis. American Society of Nephrology. https://doi.org/10.2215/CJN.06820619    

              Improving Healthcare for the Common Good (IPRO) (2017). Infection control in hemodialysis: Training curriculum. Connecticut Department of Public Health, Division of Healthcare Associated Infections. https://portal.ct.gov/-/media/Departments-and-Agencies/DPH/dph/HAI/PDF/Trainer-Guide---Final.pdf